A nurse is caring for four clients. Which of the following clients is at the greatest risk for falling?

A client who has diminished vision ambulating in well-lit areas

A client who received a diuretic 30 min ago

A client who requires assistance with ambulation

A client who had a tonic-clonic seizure 2 hr ago

Answer and Explanation

The Correct Answer is D

A.   A client with diminished vision ambulating in well-lit areas may be at risk for falling but is not at the greatest risk among the options provided.
B.   A client who received a diuretic 30 min ago may experience orthostatic hypotension, which can increase the risk of falling, but it is not the highest risk.
C.   A client who requires assistance with ambulation is generally at a lower risk than a client who has recently experienced a tonic-clonic seizure.
D.   A client who had a tonic-clonic seizure 2 hr ago is at the greatest risk for falling due to potential residual weakness, disorientation, or postictal state following the seizure.

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Correct Answer is A

Explanation

A. Applying a moisture barrier helps protect the skin from irritation and breakdown due to prolonged exposure to moisture.
B. Cleansing the skin with antibacterial soap and hot water may be too harsh and can contribute to skin irritation; gentle cleaning with a mild cleanser is preferable.
C. Toileting the client every 4 hours may not be frequent enough to prevent skin breakdown; a more frequent toileting schedule should be implemented.
D. Reducing the client's daily fluid intake is not a recommended intervention for urinary incontinence, as it may lead to dehydration and other health issues.

A. Ask the assistive personnel to witness the wasting of the controlled substance. B. Dispose of the wasted medication into a sharps container. C. Record the amount of medication wasted on the controlled substance inventory record. D. Return the unused portion of the medication to the pharmacy.

Correct Answer is C

Explanation

A. Controlled substances typically require a licensed nurse or provider to witness the wasting, not assistive personnel.
B. Wasted medication should be disposed of according to facility policies but not necessarily in a sharps container unless it is a sharp object.
C. Recording the amount of medication wasted on the controlled substance inventory record is a crucial step to maintain accurate documentation.
D. Returning the unused portion of a controlled substance to the pharmacy is not an appropriate action and goes against medication safety protocols. Controlled substances should be wasted and documented properly.

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A nurse is caring for four clients. Which of the following clients is at the greatest risk for falling?

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